Leelakrishna Nallamshetty

Dural ectasia in the Marfan syndrome: MR and CT findings and criteria

Purpose: To create criteria for detecting dural ectasia on MR or CT images in adult Marfan patients.Methods: Images were analyzed using a workstation. Parameters that predicted dural ectasia were included in our criteria.Results: Major criteria include: (1) width of dural sac below L5 > width above L4; (2) anterior sacral meningocele. Minor criteria include: (1) L5 nerve root sleeve diameter > 6.5 mm and (2) S1 scalloping > 3.5. Dural ectasia exists if 1 major or 2 minor criteria are present.Conclusion: MR and CT diagnose dural ectasia with high specificity and sensitivity. Our criteria accurately diagnose dural ectasia in adult Marfan patients.

Dural ectasia is associated with back pain in Marfan syndrome

Study Design. A cross-sectional age- and sex-matched study comparing the prevalence and size of dural ectasia in two groups of patients with Marfan syndrome. Group I comprised patients with moderate to severe back pain and Group II comprised patients without back pain. Objectives. To determine whether the presence and size of dural ectasia is associated with back pain in patients with Marfan syndrome. Summary of Background Data. Dural ectasia is present in more than 60% of patients with Marfan syndrome. Moderate to severe back pain is present in more than 50% of patients with Marfan syndrome. Most cases of significant low back pain in patients with Marfan syndrome do not have a clear cause. It would be useful for the clinician to know whether dural ectasia may be a cause of back pain in patients with Marfan syndrome with no other source. Methods. Thirty two volunteers aged 30–50 with Marfan syndrome were enrolled as age- and sex-matched pairs with significant back pain (Group I) and without back pain (Group II). A completed questionnaire, physical examination, and magnetic resonance image of the lumbosacral spine were obtained. Dural volume caudal to L5 was calculated from the magnetic resonance data by specially designed software. Results. Dural ectasia was present in 76% of the patients in Group I, and 41% of the patients in Group II. The proportion of patients with dural ectasia was significantly higher in Group I. Furthermore, the mean dural volume was significantly higher in Group I, and a significant correlation between dural volume and Oswestry pain score was noted. Conclusions. The presence and size of dural ectasia are associated with back pain in the Marfan syndrome. However, a high prevalence of dural ectasia (41%) exists even in patients with Marfan syndrome without back pain. The mere presence of dural ectasia therefore does not necessarily mean the patient will be symptomatic even though the two are associated.

Prediction of coronary artery plaque progression and potential rupture from 320-detector row prospectively ECG-gated single heart beat CT angiography: Lattice Boltzmann evaluation of endothelial shear stress

Advances in MDCT will extend coronary CTA beyond the morphology data provided by systems that use 64 or fewer detector rows. Newer coronary CTA technology such as prospective ECG-gating will also enable lower dose examinations. Since the current standard of care for coronary diagnoses is catheterization, CT will continue to be benchmarked against catheterization reference points, in particular temporal resolution, spatial resolution, radiation dose, and volume coverage. This article focuses on single heart beat cardiac acquisitions enabled by 320-detector row CT. Imaging with this system can now be performed with patient radiation doses comparable to catheterization. The high image quality, excellent contrast opacification, and absence of stair-step artifact provide the potential to evaluate endothelial shear stress (ESS) noninvasively with CT. Low ESS is known to lead to the development and progression of atherosclerotic plaque culminating in high-risk vulnerable plaque likely to rupture and cause an acute coronary event. The magnitude of local low ESS, in combination with the local remodeling response and the severity of systemic risk factors, determines the natural history of each plaque. This paper describes the steps required to derive an ESS map from 320-detector row CT data using the Lattice Boltzmann method to include the complex geometry of the coronary arterial tree. This approach diminishes the limitations of other computational fluid dynamics methods to properly evaluate multiple coronary arteries, including the complex geometry of coronary bifurcations where lesions tend to develop.

Cauda equina syndrome in ankylosing spondylitis (the CES-AS syndrome) : Meta-analysis of outcomes after medical and surgical treatments

The cauda equina syndrome in ankylosing spondylitis (the CES-AS syndrome) is marked by slow, insidious progression and a high incidence of dural ectasia in the lumbosacral spine. A high index of suspicion for this problem must be maintained when evaluating the patient with ankylosing spondylitis with a history of incontinence and neurologic deficit on examination. There has been disagreement in the literature as to whether surgical treatment is warranted for this condition. A meta-analysis was thus performed comparing outcomes with treatment regimens. Our results suggest that leaving these patients untreated or treating with steroids alone is inappropriate. Nonsteroidal antiinflammatory drugs may improve back pain but do not improve neurologic deficit. Surgical treatment of the dural ectasia, either by lumboperitoneal shunting or laminectomy, may improve neurologic dysfunction or halt the progression of neurologic deficit.

Osseous anatomy of the lumbosacral spine in Marfan syndrome.

Study Design. This study examines pedicle widths, laminar thicknesses, and scalloping values for lumbosacral spine elements in Marfan volunteers. Comparisons were made between these measurements and norms as well as measurements between Marfan patients with and without dural ectasia. Objectives. To determine if the lumbosacral vertebral elements are altered in the patient with Marfan syndrome. Summary of Background Data. Several abnormalities have been noted in Marfan lumbar spine, including pedicular attenuation and widened interpediculate distances. This may be due to abnormalities of growth or presence of dural ectasia. Given the large numbers of Marfan patients requiring spinal surgery and the high postoperative failure rate, better understanding of the bony anatomy of Marfan lumbar spine is necessary, especially if use of instrumentation is anticipated. Methods. Thirty-two volunteers with Marfan syndrome based on the Ghent criteria underwent spiral computed tomography of the lumbosacral spine. Images were evaluated for dural ectasia, and measurements of pedicle width, laminar thickness, and vertebral scalloping were made. Results. Pedicle widths and laminar thicknesses were significantly smaller in Marfan patients at all levels (P < 0.001). Mean pedicle widths at L1–L3 were smaller than the smallest available pedicle screw (5 mm). In Marfan patients with dural ectasia, laminar thickness from L5–S2 and pedicle widths at all lumbar levels were significantly reduced (P < 0.01). Vertebral scalloping at S1 was significantly greater in Marfan patients with dural ectasia (P = 0.02). Conclusion. Lumbar pedicle width and laminar thickness are significantly reduced in Marfan individuals. Those with dural ectasia demonstrate increased bony erosion of anterior and posterior elements of lumbosacral spine. Preoperative planning and routine computed tomography scans are recommended when operating on Marfan lumbosacral spine.

Thoracolumbar Spinal Abnormalities in Stickler Syndrome

Study Design Retrospective review of clinical and radiographic records of patients with Stickler syndrome. Objectives To describe thoracolumbar spinal abnormalities and their correlation with age and back pain among patients with Stickler syndrome. Summary of Background Data Stickler syndrome (hereditary arthro-ophthalmopathy) is an autosomal dominant connective tissue disorder characterized by skeletal, ocular, oral–facial, cardiac, and auditory manifestations. Prevalence is approximately 1 in 10,000 (similar to that of Marfan syndrome). No one has investigated spinal abnormalities in a large series of patients. Methods A single-center evaluation of 53 patients from 24 families with Stickler syndrome (age range, 1–70 years) in a multidisciplinary genetics clinic. Thoracolumbar radiographs were analyzed for spinal abnormalities and correlation with age and back pain. Results Thirty-four percent of patients had scoliosis, 74% endplate abnormalities, 64% Schmorl’s nodes, 43% platyspondylia, and 43% Scheuermann-like kyphosis. Sixty-seven percent of patients and 85% of adults reported chronic back pain. Endplate abnormalities and Schmorl’s nodes were associated with adult age; endplate abnormalities, Schmorl’s nodes, and adult age were associated with back pain. Only one adult patient was free of spinal abnormalities. Conclusions Spinal abnormalities are nearly uniformly observed in Stickler syndrome, progress with age, and are associated with back pain. Although common, scoliosis is generally self-limited (only one patient needed surgical treatment). Correct diagnosis of this syndrome facilitates early identification and management of other potentially severe systemic manifestations and genetic counseling for affected families. Moreover, recognition of Stickler syndrome allows accurate prognosis for skeletal abnormalities and anticipation of potential surgical complications.

Septic arthritis of the hip following cortisone injection Case report and review of the literature

Septic arthritis of the hip is a serious medical condition that can result in permanent joint dysfunction. This is a case of a 65-year-old woman who underwent therapeutic intraarticular steroid/lidocaine injection for hip pain and subsequently developed septic arthritis. It is critical that radiologists performing these procedures maintain a high index of suspicion in symptomatic patients following intraarticular injections to prevent destruction of the joint.

Dural ectasia and back pain: review of the literature and case report.

Dural ectasia is defined as a ballooning of the dural sac which is more common in patients with connective tissue disorders such as the Marfan syndrome. Several studies have shown that dural ectasia may be associated with such conditions as back pain, headaches, radiculopathies, or incontinence. We present a case of a 52 year old woman with Marfan syndrome who presented with a significantly large anterior sacral meningocele without having associated symptoms. In light of this case, we recommend that asymptomatic Marfan patients with dural ectasia should be closely observed without need for immediate surgical intervention.

Myocarditis: Diagnosis and Treatment

Opinion statementMyocarditis is a condition that can have a very wide clinical spectrum ranging from asymptomatic forms to fatal disease, but mostly presenting as new onset heart failure with reduced left ventricular ejection fraction, with or without viral syndrome. This condition is an important cause of sudden cardiac death in young patients. High risk features include second and third degree atrioventricular block or malignant arrhythmias. The diagnostic work-up may be challenging, but non-invasive imaging, primarily cardiac magnetic resonance, plays an increasingly important role, although endomyocardial biopsy is still considered a gold standard for diagnosis. Most importantly, myocarditis can transition to non-ischemic cardiomyopathy with eventually poor outcome. In this review, we will summarize the data on different diagnostic and treatment modalities of this disease.

Aspiration-related lung diseases.

Aspiration is a common but underrecognized clinicopathologic entity, with varied radiographic manifestations. Aspiration represents a spectrum of diseases, including diffuse aspiration bronchiolitis, aspiration pneumonitis, airway obstruction by foreign body, exogenous lipoid pneumonia, interstitial fibrosis, and aspiration pneumonia with or without lung abscess formation. Many patients who aspirate do not present with disease, suggesting that pathophysiology is related to a variety of factors, including decreased levels of consciousness, dysphagia, impaired mucociliary clearance, composition of aspirate, and impaired host defenses. In this pictorial essay, we will review the different types of aspiration lung diseases, focusing on their imaging features and differential diagnosis.